1. ECG Rounds
©Aric Storck
Shawn Dowling
PGY-2

2. Case #1
39M
DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis
Presents w/++NV, developed epigastric/CP
O/E – HR 130, BP 70/30,
Fluid: Dry, anuric
Cardiac exam - Normal

5. Pt got ‘lytics K+ was 8.9, Cr was 252
ECG did not change w/lytics, but with insulin/bicarb…

7. Case #2 87F Feeling weak and dizzy PMHx – heart failure, prior MI
Meds - on some heart meds – you know the little white ones…
ECG…

8. What do you think? How do you want to treat this patient?

9. A few hours later the clinical clerk shows you her repeat ECG, and says “cool I’ve never seen an ECG like this…”
Do you want to change any of your meds for treating her high K?

10. Case #3 79M 2 hrs of RSCP (good story for ischemia)
Cardiac RF: all of ‘em
ECG…

12. What does hyperacute ischemic T waves have to do w/high K?

13. Summary ECG findings Peaked T-waves (>5mm) QT shortening
ST elevation
Increased PR/loss of P wave
Widening/Slurring QRS
Sine wave appearance
2nd/3rd degree block, VF, asystole
Mild
Moderate
Severe

14. Although the ECG findings may or may not correlate to lab findings, arrhythmias can any level of hyperkalemia

15. Drug Dosage Onset/Duration Ca Cl or Gluconate 10mL of 10% over
10 mins (Cl = 360mg, Gl=93mg)
O:0-5 mins D:1 hr
Glucose & (Insulin)
10-20u bolus
(if c/s <14mmol)
O: 15 mins D: 4-6 hrs
Effect –
Ventolin
Nebs 5-20 mg
IV 0.5mg
O: 15 mins D: 2-3 hrs
E: N /IV
Na Bicarbonate
One Amp (44mEq)
O: 15 mins D: 2 hrs
4 studies – 0  but small studies (5-10 pts)
Lasix
10-80mg IV
O: 1 hr D: 2-4 hrs
Dialysis
1 nephrology resident
E: mEq/hr
Kayexalate
Pt nice=PO 20gm
Pt nasty=PR 50gm
PO onset 1-2hrs
PR onset 30 mins
Membrane
Stabilizer*
Shift*
Excretion*
*Tx w/ at
least modality
From each

16. Case #
46M.
C/O - Feeling unwell, muscle cramping and intermittent parasthesias
Admits to laxative abuse
VSS
ECG…

19. ECG findings small or absent T waves prominent U waves
ST segment depression
QT prolongation/Pseudo
VF/Torsades

20. Tx* Mild (3-3.4mEq) Moderate (2.5-3.0 mEq) Severe (<2.5 mEq)
PO replacement
Moderate ( mEq)
Minimal Sx and N ECG – PO replacement
Significant Sx and/or ECG changes – IV
Severe (<2.5 mEq)
IV KCl
*Check Magnesium – replace if low or borderline

21. K deficit = desired K – meas K x .25 x wgt (kg)
Only an approximation since most K is intracellular
Want to replace 75% of K w/i 1st 24 hrs

22. Oral IV S/E’s K-Dur (20mmol/tab) KCl (10/20/40mmol/100cc)
KCl elixir(20mmol/15ml)
K-Phos(4.4mmol/ml)
useful if hypophosphatemic
K-Citrate (0.9mmol/ml)
useful in RTA IV
KCl (10/20/40mmol/100cc)
10-20mEq/h
>20mEq/h requires central line and cardiac monitor
S/E’s
transient hyperkalemia
burning at IV site
Thanks for the slide Aric

23. References
Rosen’s
eMedicine.com